APPLICATION FOR ANNUITY BENEFIT

Transcription

1 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, IL Fax APPLICATION FOR ANNUITY BENEFIT The following forms are necessary to begin your annuity: 1. Application for Annuity Benefit 2. Payment Election for Pension Plan Distribution (if withdrawing or rolling over personal portion) 3. Authorization Agreement for Automatic Deposit (ACH Credits) 4. Tax Withholding Information If you are married and applying for a single life annuity, your spouse must sign the Election of Single Life Annuity Option form, and a copy of your birth certificate or passport is required. The form will also need to be notarized. If applying for a survivor benefit, we require a copy of birth certificates or passports for you and your spouse. A copy of a marriage certificate is also required. Your annuity will not begin without receipt of the above referenced documents. Revised 10/2011

2 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, IL Fax Annuity Benefit Options When you wish to retire and begin your annuity, the amount you will receive each month will be calculated by staff in the Pension Plan office. In simple terms, the money you have in the Plan when you begin receiving payments will be divided by the number of months that actuarial tables say you are expected to live. However, the size of the payment will also reflect The anticipated future earnings on your accumulations. Which of your various options you choose. If you are married, whether you choose a payment option that would continue to give your spouse an annuity should you die first. Types of benefits Most retiring members have an subaccount and an employer subaccount. The employee subaccount consists of the contributions made by the employee during the years of service plus the earnings on those contributions. The employer subaccount consists of the contributions made by the employer plus the earnings on those contributions. Money from the employer subaccount is used to fund your monthly annuity. You have choices about what to do with the money in your employee subaccount You may stipulate that the employee subaccount be combined with the employer subaccount to fund your monthly annuity. You may take the employee subaccount as a lump-sum withdrawal at the time the annuity begins. You may take a partial lump-sum withdrawal from the employee subaccount and combine the remainder with the employer subaccount to fund your monthly annuity. You may leave your employee subaccount in the BBT investment program, where it will remain fully invested in whatever funds you designate. You may take a partial lump-sum withdrawal from your employee subaccount and leave the remainder in the BBT investment program. Revised 9/2010 Page 1 of 2 P-2ANBEN.qxp

3 Types of payment When you apply for your annuity you will be asked to select one of the following payment options Single Life Annuity Payments will be made in equal monthly amounts during your lifetime, and they will stop when you die. If you are married, your spouse must sign a consent form before payments begin. Surviving Spouse Option Your monthly payment will be somewhat lower than for a single life annuity, but your spouse will receive a surviving spouse annuity if he or she lives longer than you do. 50 percent spouse annuity If you die before your spouse, your spouse will receive a monthly payment equal to 50 percent of the amount you were receiving. If your spouse dies first, you continue to receive the same size payment. 75 percent spouse annuity If you die before your spouse, your spouse will receive a monthly payment equal to 75 percent of the amount you were receiving. If your spouse dies first, you continue to receive the same size payment. 100 percent spouse annuity The same monthly payment will be paid as long as you or your spouse is living. Your monthly payment will be highest if you select a single life annuity and lowest if you select a 100 percent spouse option. We encourage you to give these decisions careful consideration. Once your annuity begins, it cannot be changed. For additional information, see your Church of the Brethren Pension Plan Participants Handbook or call the Pension Plan office. Three months before you wish to start your annuity, contact the Pension Plan office. You will be sent the application forms and information about the size of your annuity. Annuities cannot be made retroactively. The annuity application must be returned with a copy of your birth certificate or a copy of your passport. If you are choosing a surviving spouse option, you will also need to include a copy of your spouse s birth certificate or a copy of his/her passport, and a copy of your marriage certificate. A completed application and required forms must be received by BBT before your beginning annuity date. Revised 9/2010 Page 2 of 2 P-2ANBEN.qxp

4 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, IL Fax Application for Annuity Benefit A completed application and required forms must be received by Brethren Benefit Trust before your beginning annuity date. 1. INFORMATION ABOUT YOU Name: Gender: Male Female Social Security Number: Date of birth: Daytime Phone Number: Address: City: State: ZIP: 2. INFORMATION ABOUT YOUR SPOUSE Name: Gender: Male Female Social Security Number: Date of Birth: If Deceased, Date of Death: 3. WITH THIS FORM SEND PROOF OF AGE FOR YOURSELF, PROOF OF AGE FOR YOUR SPOUSE, AND PROOF OF MARRIAGE. Proofs needed are: Birth Photocopy of birth certificate or photocopy of passport. Marriage Photocopy of marriage certificate, obtainable from the county in which you were married. 4. WHEN YOU WOULD LIKE YOUR ANNUITY TO BEGIN First of month Year (cannot be retroactive) VERY IMPORTANT: Enclose a cancelled check and fill out and sign the enclosed form, Authorization Agreement for Automatic Deposit. Please give these decisions careful consideration. Once your annuity begins, it cannot be changed. For additional information see your Church of the Brethren Pension Plan Participants Handbook or call the Pension Plan office. Revised 11/2011 P-7APP.qxp

5 5. TYPE OF BENEFIT (CHOOSE ONE) A monthly annuity based on all the contributions and earnings in both your personal and employer pension accounts. A lump sum withdrawal of your entire personal account (your contributions and the earnings on those contributions), and a monthly annuity based on your employer account. A partial lump sum withdrawal of your personal account in the amount of $ and a monthly annuity based on your employer account and what remains in your personal account. A monthly annuity based on your employer account, leaving your personal account in the BBT investment program. A monthly annuity based on your employer account,with a partial lump-sum withdrawal of $, leaving the remaining personal account in the BBT investment program. If you choose to take a total or partial lump-sum withdrawal, you must complete the form entitled Payment Election for Pension Plan Distribution. 6. TYPE OF PAYMENT (CHOOSE ONE) Single life annuity 50 percent survivor option 75 percent survivor option 100 percent survivor option If you are single, you must choose this option. If you are married, you may choose this option as long as your spouse consents. (Important: If you are married and you select this option, you and your spouse must complete the Election of Single Life Annuity Option Form on the back page of this form.) Your spouse will receive 50 percent of your monthly annuity if you die first. Your spouse will receive 75 percent of your monthly annuity if you die first. Your spouse will receive the same size monthly annuity if you die first. 7. LIST YOUR CONTINGENT BENEFICIARY OR BENEFICIARIES Beneficiaries are persons who would receive any remaining assured return from your Pension account when you and your spouse are deceased. Unless you designate otherwise, any remaining assured return (your personal contributions and the investment return on those contributions) would be divided equally among the surviving contingent beneficiaries. Name: Address: City: State: ZIP: Relationship to you: Name: Address: City: State: ZIP: Relationship to you: Revised 11/2011 P-7APP.qxp

6 Name: Address: City: State: ZIP: Relationship to you: Name: Address: City: State: ZIP: Relationship to you: 8. IN ACCORDANCE WITH THE PROVISIONS OF THE CHURCH OF THE BRETHREN PENSION PLAN, I AM HEREBY APPLYING FOR MY ANNUITY. Plan member s signature: Spouse s signature: Date: NOTE: If you are applying for a disability benefit (before your plan s retirement age), please send a statement from your physician with this form. It should include your date of disability, diagnosis, prognosis, and treatment plan, if any. This information needs to be approved by the Pension Plan office before your benefit begins. See back page for Election of Single Life Annuity Option Form. Revised 11/2011 P-7APP.qxp

7 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, IL Fax Election of Single Life Annuity Option Complete this page only if you are married and you selected the single life annuity in Section 6 on the inside of this form. Please note: This form must be notarized. I,, hereby elect the single life annuity option available to me as a member of the Church of the Brethren Pension Plan. This election entitles me to an annuity on my life only. My spouse understands that his/her right to receive any part of my annuity benefit (other than any remaining assured return) upon my death is irrevocably forfeited. Plan member s signature: Spouse s signature: Date: I,, a notary public in and for and residing in County in the state of, certify that and, personally known to me to be the same persons whose names are subscribed to in the foregoing instrument, appeared before me in person and acknowledged that they signed, sealed, and delivered the said instrument as their free and voluntary act. Given under my hand and seal the day of, (year). Signature: Revised 10/2011 P-7APP.qxp

8 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, IL Fax Payment Election for Pension Plan Distribution Please read before completing form. USE THIS FORM TO ELECT DISTRIBUTION OF PENSION PLAN FUNDS WHEN YOU Request a lump-sum payment from your employee subaccount at the time your annuity starts (refer to your Participants Handbook). Decide to withdraw all or part of the amount in your employee subaccount when you leave your position. Have less than $5,000 in your vested employer subaccount when you leave your job and are required to cash out your entire Plan account. Request, as beneficiary (other than spouse), the total amount in the Plan account of a Plan member who died before his/her annuity started. BEFORE FILLING OUT THE FORM, READ THE FOLLOWING CAREFULLY Federal law requires that Church of the Brethren Benefit Trust Inc., must withhold tax from 403(b) plan distributions eligible for rollover at the rate of 20 percent UNLESS these plan distributions are transferred directly to an eligible 403(b) retirement plan, IRA, or other qualified plan as allowed by law. Withholding applies only to the portion of your distribution that is subject to tax. Any portion of your distribution from Church of the Brethren Benefit Trust Inc., that is a return of your after-tax contributions is not eligible for direct rollover and thus will be paid directly to you. It is not taxed and therefore no withholding will be taken on this amount. We urge you to consult a professional tax adviser to understand the tax consequences connected with your choice. Return this form with your Application for Annuity Form or your Withdrawal Form and send to: Church of the Brethren Pension Plan 1505 Dundee Avenue Elgin, IL Revised 2/2012 P-27PAEL.qxp

9 Payment Election for Pension Plan Distribution Please read reverse side before completing form. Your application cannot be processed unless this form is complete. 1. PLAN MEMBER INFORMATION Name of Plan Member: SSN: Address: City: State: ZIP: Reason for distribution (check one): Lump sum at retirement Withdrawal Cash out Death 2. PAYMENT ELECTION Please check one of the following boxes: A. I elect to have my full taxable account balance or $ (less withholding) PAID TO ME. I understand that 20 percent withholding will be applicable. (We do not withhold if the dollar amount is less than $200.) B. I elect a direct transfer ($500 minimum required) of my full taxable account balance or $. (See payment transfer instructions below.) I understand the full amount of the actual contributions in my tax-paid contributions account will be paid to me under either election. 3. PAYMENT TRANSFER INSTRUCTIONS I elect to transfer a portion of my taxable account balance noted in B above to the following eligible transferee (check one): IRA 403(b) retirement plan Percentage of taxable amount to be transferred (1 to 100 percent) % or $ If I elect to transfer less than 100 percent, the remainder (less withholding), $, will be paid to me. Payable to: Name of 403(b) plan or IRA sponsor) Account Number: Address: City: State: ZIP: 4. SIGNATURE I understand that a direct transfer payment must be payable to the trustee or sponsor of the eligible transferee plan. I have read the special tax notice regarding Plan payments and understand the tax consequences of the above election. Signed: Date: Return this form with your Application for Annuity Form or your Withdrawal Form. Revised 2/2012 P-27PAEL.qxp

10 Direct Deposit (ACH) 403(b) Plan Use black or blue ink when completing this form. Use only for Automated Minimum Distributions and Periodic Payments. For questions regarding this form, visit the Web site at or contact Service Provider at BBT - Retired Trust D1 A Participant Information Account extension identifies funds transferred to a beneficiary due to death, alternate payee due to divorce or a participant with multiple accounts. Account Extension Last Name First Name M.I. Address B Financial Institution Information (A business account or an IRA may not be designated.) - - Social Security Number (Must provide all 9 digits) ( ) Daytime Phone Number ( ) Alternate Phone Number Checking Account - Attach a copy of a preprinted voided check for the receiving account or letter on financial institution letterhead signed by a representative from the receiving institution which includes my name, checking account number and ABA routing number. Savings Account - Attach a letter on financial institution letterhead signed by a representative from the receiving institution which includes my name, savings account number and ABA routing number. Automated Clearing House (ACH) credit can only be made into a United States financial institution. Any requests received referencing a foreign financial institution or referencing a United States financial institution with a further credit to an account associated with a foreign financial institution will be rejected. If your payment start date does not allow for the 10 day pre-notification process, your first payment will be sent by check to your address of record. C Participant Consent Allow at least 15 days from the date Service Provider receives a properly completed Direct Deposit form to begin using ACH for your payments. By requesting my distribution via ACH deposit, I certify, represent and warrant that the account requested for an ACH deposit is established at a financial institution or a branch of a financial institution located within the United States and there are no standing orders to forward any portion of the ACH deposit to an account that exists at a financial institution or a branch of a financial institution in another country. I understand that it is my obligation to request a stop to this ACH deposit request if an order to transfer any portion of payments to a financial institution or a branch of a financial institution outside the United States will be implemented in the future. Service Provider reserves the right to reject the ACH request and deliver any payment via check in lieu of direct deposit. I hereby authorize the initiation of credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my checking or savings account at the financial institution as referenced in the attached documentation, in the form of an ACH transfer. I understand that payments will be made in accordance with the directions I have specified on this form until I cancel this agreement in writing. Notice of cancellation must be made by me at least 30 days prior to a payment date for the cancellation to be effective with respect to my subsequent payments. I understand that Service Provider reserves the right to terminate the authorization agreement for ACH transfers for any reason and will notify me in the event of such termination by sending notice to my last known address on file. I acknowledge that it is my obligation to provide notification of any address or other changes affecting my electronic fund transfers during my lifetime. I am solely responsible for any liability that may arise out of my failure to provide such notification affecting my ACH transfers. I agree that Service Provider is not liable for payments made in accordance with this properly completed Direct Deposit form. I hereby authorize and direct my financial institution not to hold any overpayments made on my behalf or on behalf of my estate or any current or future joint account holder, if applicable. I understand that if this form is not completed properly, payments will be made by check and mailed directly to me at my last known mailing address on file. Any person who presents a false or fraudulent claim is subject to criminal and civil penalties. Participant Signature Date (Required) D Mailing Instructions This form can be sent by Fax to: OR Regular Mail to: Great-West Retirement Services PO Box Denver, CO OR Express Mail to: Great-West Retirement Services 8515 E. Orchard Road Greenwood Village, CO STD FACHTR ][06/12/13)( D1 ACHDIRDEP ][GP22)(/][ )( Page 1 of 1

11 Form W-4P Department of the Treasury Internal Revenue Service Withholding Certificate for Pension or Annuity Payments OMB No Purpose. Form W-4P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s). You also may use Form W-4P to choose (a) not to have any federal income tax withheld from the payment (except for eligible rollover distributions or payments to U.S. citizens delivered outside the United States or its possessions) or (b) to have an additional amount of tax withheld. Your options depend on whether the payment is periodic, nonperiodic, or an eligible rollover distribution, as explained on pages 3 and 4. Your previously filed Form W-4P will remain in effect if you do not file a Form W-4P for What do I need to do? Complete lines A through G of the Personal Allowances Worksheet. Use the additional worksheets on page 2 to further adjust your withholding allowances for itemized deductions, adjustments to income, any additional standard deduction, certain credits, or multiple pensions/more-than-one-income situations. If you do not want any federal income tax withheld (see Purpose, earlier), you can skip the worksheets and go directly to the Form W-4P below. Sign this form. Form W-4P is not valid unless you sign it. Future developments. The IRS has created a page on IRS.gov for information about Form W-4P and its instructions, at Information about any future developments affecting Form W-4P (such as legislation enacted after we release it) will be posted on that page. Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A } { You are single and have only one pension; or You are married, have only one pension, and your spouse B Enter 1 if: has no income subject to withholding; or B Your income from a second pension or a job or your spouse s pension or wages (or the total of all) is $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a spouse who has income subject to withholding or more than one source of income subject to withholding. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return..... D E Enter 1 if you will file as head of household on your tax return E F Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $65,000 ($100,000 if married), enter 2 for each eligible child; then less 1 if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter 1 for each eligible child F G Add lines A through F and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) G For accuracy, complete all worksheets that apply. { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. If you are single and have more than one source of income subject to withholding or are married and you and your spouse both have income subject to withholding and your combined income from all sources exceeds $50,000 ($20,000 if married), see the Multiple Pensions/More-Than-One-Income Worksheet on page 2 to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line G on line 2 of Form W-4P below. Separate here and give Form W-4P to the payer of your pension or annuity. Keep the top part for your records. OMB No Form W-4P Withholding Certificate for Pension or Annuity Payments 2015 Department of the Treasury Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice, see page 4. Your first name and middle initial Last name Your social security number Home address (number and street or rural route) City or town, state, and ZIP code Claim or identification number (if any) of your pension or annuity contract Complete the following applicable lines. 1 Check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete line 2 or 3.) 2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity payment. (You also may designate an additional dollar amount on line 3.) Marital status: Single Married Married, but withhold at higher Single rate. 3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note. For periodic payments, you cannot enter an amount here without entering the number (including zero) of allowances on line 2.).... $ (Enter number of allowances.) Your signature Date Cat. No T Form W-4P (2015)

12 Form W-4P (2015) Page 2 Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. 1 Enter an estimate of your 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $154,950 if you are single and not head of household or a qualifying widow(er); or $258,250 if you are married filing separately. See Pub. 505 for details $ $12,600 if married filing jointly or qualifying widow(er) 2 Enter: { $9,250 if head of household } $ $6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter $ 4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) $ 5 Add lines 3 and 4 and enter the total. (Include any credit amounts from the Converting Credits to Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505.) $ 6 Enter an estimate of your 2015 income not subject to withholding (such as dividends or interest).. 6 $ 7 Subtract line 6 from line 5. If zero or less, enter $ 8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction Enter the number from the Personal Allowances Worksheet, line G, page Add lines 8 and 9 and enter the total here. If you use the Multiple Pensions/More-Than-One-Income Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4P, line 2, page Multiple Pensions/More-Than-One-Income Worksheet Note. Complete only if the instructions under line G, page 1, direct you here. This applies if you (and your spouse if married filing jointly) have more than one source of income subject to withholding (such as more than one pension, or a pension and a job, or you have a pension and your spouse works). 1 Enter the number from line G, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) Find the number in Table 1 below that applies to the LOWEST paying pension or job and enter it here. However, if you are married filing jointly and the amount from the highest paying pension or job is $65,000 or less, do not enter more than If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter -0- ) and on Form W-4P, line 2, page 1. Do not use the rest of this worksheet Note. If line 1 is less than line 2, enter -0- on Form W-4P, line 2, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet Enter the number from line 1 of this worksheet Subtract line 5 from line Find the amount in Table 2 below that applies to the HIGHEST paying pension or job and enter it here 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed.. 8 $ 9 Divide line 8 by the number of pay periods remaining in For example, divide by 12 if you are paid every month and you complete this form in December Enter the result here and on Form W-4P, line 3, page 1. This is the additional amount to be withheld from each payment $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others If wages from LOWEST paying job or pension are Enter on line 2 above If wages from LOWEST paying job or pension are Enter on line 2 above If wages from HIGHEST paying job or pension are Enter on line 7 above If wages from HIGHEST paying job or pension are Enter on line 7 above $0 - $6, ,001-13, ,001-24, ,001-26, ,001-34, ,001-44, ,001-50, ,001-65, ,001-75, ,001-80, , , , , , , , , , , ,001 and over 15 $0 - $8, ,001-17, ,001-26, ,001-34, ,001-44, ,001-75, ,001-85, , , , , , , ,001 and over 10 $0 - $75,000 $600 75, ,000 1, , ,000 1, , ,000 1, , ,000 1, ,001 and over 1,580 $0 - $38,000 $600 38,001-83,000 1,000 83, ,000 1, , ,000 1, ,001 and over 1,580

13 Form W-4P (2015) Page 3 Additional Instructions Section references are to the Internal Revenue Code. When should I complete the form? Complete Form W-4P and give it to the payer as soon as possible. Get Pub. 505, Tax Withholding and Estimated Tax, to see how the dollar amount you are having withheld compares to your projected total federal income tax for You also may use the IRS Withholding Calculator at for help in determining how many withholding allowances to claim on your Form W-4P. Multiple pensions/more-than-one-income. To figure the number of allowances that you may claim, combine allowances and income subject to withholding from all sources on one worksheet. You may file a Form W-4P with each pension payer, but do not claim the same allowances more than once. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4P for the highest source of income subject to withholding and zero allowances are claimed on the others. Other income. If you have a large amount of income from other sources not subject to withholding (such as interest, dividends, or capital gains), consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Call TAX-FORM ( ) to get Form 1040-ES and Pub You also can get forms and publications at If you have income from wages, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or Form W-4P. Note. Social security and railroad retirement payments may be includible in income. See Form W-4V, Voluntary Withholding Request, for information on voluntary withholding from these payments. Withholding From Pensions and Annuities Generally, federal income tax withholding applies to the taxable part of payments made from pension, profit-sharing, stock bonus, annuity, and certain deferred compensation plans; from individual retirement arrangements (IRAs); and from commercial annuities. The method and rate of withholding depend on (a) the kind of payment you receive; (b) whether the payments are delivered outside the United States or its commonwealths and possessions; and (c) whether the recipient is a nonresident alien individual, a nonresident alien beneficiary, or a foreign estate. Qualified distributions from a Roth IRA are nontaxable and, therefore, not subject to withholding. See page 4 for special withholding rules that apply to payments outside the United States and payments to foreign persons. Because your tax situation may change from year to year, you may want to refigure your withholding each year. You can change the amount to be withheld by using lines 2 and 3 of Form W-4P. Choosing not to have income tax withheld. You (or in the event of death, your beneficiary or estate) can choose not to have federal income tax withheld from your payments by using line 1 of Form W-4P. For an estate, the election to have no income tax withheld may be made by the executor or personal representative of the decedent. Enter the estate s employer identification number (EIN) in the area reserved for Your social security number on Form W-4P. You may not make this choice for eligible rollover distributions. See Eligible rollover distribution 20% withholding on page 4. Caution. There are penalties for not paying enough federal income tax during the year, either through withholding or estimated tax payments. New retirees, especially, should see Pub It explains your estimated tax requirements and describes penalties in detail. You may be able to avoid quarterly estimated tax payments by having enough tax withheld from your pension or annuity using Form W-4P. Periodic payments. Withholding from periodic payments of a pension or annuity is figured in the same manner as withholding from wages. Periodic payments are made in installments at regular intervals over a period of more than 1 year. They may be paid annually, quarterly, monthly, etc. If you want federal income tax to be withheld, you must designate the number of withholding allowances on line 2 of Form W-4P and indicate your marital status by checking the appropriate box. Under current law, you cannot designate a specific dollar amount to be withheld. However, you can designate an additional amount to be withheld on line 3. If you do not want any federal income tax withheld from your periodic payments, check the box on line 1 of Form W-4P and submit the form to your payer. However, see Payments to Foreign Persons and Payments Outside the United States on page 4. Caution. If you do not submit Form W-4P to your payer, the payer must withhold on periodic payments as if you are married claiming three withholding allowances. Generally, this means that tax will be withheld if your pension or annuity is at least $1,720 a month. If you submit a Form W-4P that does not contain your correct social security number (SSN), the payer must withhold as if you are single claiming zero withholding allowances even if you checked the box on line 1 to have no federal income tax withheld. There are some kinds of periodic payments for which you cannot use Form W-4P because they are already defined as wages subject to federal income tax withholding. These payments include retirement pay for service in the U.S. Armed Forces and payments from certain nonqualified deferred compensation plans and deferred compensation plans described in section 457 of tax-exempt organizations. Your payer should be able to tell you whether Form W-4P applies. For periodic payments, your Form W-4P stays in effect until you change or revoke it. Your payer must notify you each year of your right to choose not to have federal income tax withheld (if permitted) or to change your choice. Nonperiodic payments 10% withholding. Your payer must withhold at a flat 10% rate from nonperiodic payments (but see Eligible rollover distribution 20% withholding on page 4) unless you choose not to have federal income tax withheld. Distributions from an IRA that are payable on demand are treated as nonperiodic payments. You can choose not to have federal income tax withheld from a nonperiodic payment (if permitted) by submitting Form W-4P (containing your correct SSN) to your payer and checking the box on line 1. Generally, your choice not to have federal income tax withheld will apply to any later payment from the same plan. You cannot use line 2 for nonperiodic payments. But you may use line 3 to specify an additional amount that you want withheld. Caution. If you submit a Form W-4P that does not contain your correct SSN, the payer cannot honor your request not to have income tax withheld and must withhold 10% of the payment for federal income tax.

14 Form W-4P (2015) Page 4 Eligible rollover distribution 20% withholding. Distributions you receive from qualified pension or annuity plans (for example, 401(k) pension plans and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over tax free to an IRA or qualified plan are subject to a flat 20% federal withholding rate. The 20% withholding rate is required, and you cannot choose not to have income tax withheld from eligible rollover distributions. Do not give Form W-4P to your payer unless you want an additional amount withheld. Then, complete line 3 of Form W-4P and submit the form to your payer. Note. The payer will not withhold federal income tax if the entire distribution is transferred by the plan administrator in a direct rollover to a traditional IRA or another eligible retirement plan (if allowed by the plan), such as a qualified pension plan, governmental section 457(b) plan, section 403(b) contract, or tax-sheltered annuity. Distributions that are (a) required by law, (b) one of a specified series of equal payments, or (c) qualifying hardship distributions are not eligible rollover distributions and are not subject to the mandatory 20% federal income tax withholding. See Pub. 505 for details. See also Nonperiodic payments 10% withholding on page 3. Tax relief for victims of terrorist attacks. For tax years ending after September 10, 2001, disability payments for injuries incurred as a direct result of a terrorist attack directed against the United States (or its allies), whether outside or within the United States, are not included in income. You may check the box on line 1 of Form W-4P and submit the form to your payer to have no federal income tax withheld from these disability payments. However, you must include in your income any amounts that you received or you would have received in retirement had you not become disabled as a result of a terrorist attack. See Pub. 3920, Tax Relief for Victims of Terrorist Attacks, for more details. Changing Your No Withholding Choice Periodic payments. If you previously chose not to have federal income tax withheld and you now want withholding, complete another Form W-4P and submit it to your payer. If you want federal income tax withheld at the rate set by law (married with three allowances), write Revoked next to the checkbox on line 1 of the form. If you want tax withheld at any different rate, complete line 2 on the form. Nonperiodic payments. If you previously chose not to have federal income tax withheld and you now want withholding, write Revoked next to the checkbox on line 1 and submit Form W-4P to your payer. Payments to Foreign Persons and Payments Outside the United States Unless you are a nonresident alien, withholding (in the manner described above) is required on any periodic or nonperiodic payments that are delivered to you outside the United States or its possessions. You cannot choose not to have federal income tax withheld on line 1 of Form W-4P. See Pub. 505 for details. In the absence of a tax treaty exemption, nonresident aliens, nonresident alien beneficiaries, and foreign estates generally are subject to a 30% federal withholding tax under section 1441 on the taxable portion of a periodic or nonperiodic pension or annuity payment that is from U.S. sources. However, most tax treaties provide that private pensions and annuities are exempt from withholding and tax. Also, payments from certain pension plans are exempt from withholding even if no tax treaty applies. See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and Pub. 519, U.S. Tax Guide for Aliens, for details. A foreign person should submit Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding, to the payer before receiving any payments. The Form W-8BEN must contain the foreign person s taxpayer identification number (TIN). Statement of Federal Income Tax Withheld From Your Pension or Annuity By January 31 of next year, your payer will furnish a statement to you on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., showing the total amount of your pension or annuity payments and the total federal income tax withheld during the year. If you are a foreign person who has provided your payer with Form W-8BEN, your payer instead will furnish a statement to you on Form 1042-S, Foreign Person s U.S. Source Income Subject to Withholding, by March 15 of next year. Privacy Act and Paperwork Reduction Act Notice We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to provide this information only if you want to (a) request federal income tax withholding from periodic pension or annuity payments based on your withholding allowances and marital status, (b) request additional federal income tax withholding from your pension or annuity, (c) choose not to have federal income tax withheld, when permitted, or (d) change or revoke a previous Form W-4P. To do any of the aforementioned, you are required by sections 3405(e) and 6109 and their regulations to provide the information requested on this form. Failure to provide this information may result in inaccurate withholding on your payment(s). Providing false or fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

15 Church of the Brethren Pension Plan Rollover Notice YOUR ROLLOVER OPTIONS You are receiving this notice because all or a portion of a payment you are receiving from the Church of the Brethren Pension Plan (the Plan ) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do such a rollover. This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account. Rules that apply to most payments from a plan are described in the General Information about Rollovers section. Special rules that only apply in certain circumstances are described in the Special Rules and Options section. GENERAL INFORMATION ABOUT ROLLOVERS How can a rollover affect my taxes? You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not do a rollover, you will also have to pay a 10 percent additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later, and the 10 percent additional income tax will not apply if those payments are made after you are age 59½ (or if an exception applies). Where may I roll over the payment? You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs, and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan. How do I do a rollover? There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover. If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover Dundee Avenue Elgin, Illinois Website: toll-free fax

16 If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20 percent of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20 percent withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10 percent additional income tax on early distributions if you are under age 59½ (unless an exception applies). How much may I roll over? If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary). Required minimum distributions after age 70½ (or after death). Hardship distributions. ESOP dividends. Corrective distributions of contributions that exceed tax law limitations. Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends). Cost of life insurance paid by the Plan. Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment. Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA). The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover. In general, amounts in your account attributable to employer contributions are not eligible for rollover, except for certain small payment amounts. If I don t do a rollover, will I have to pay the 10 percent additional income tax on early distributions? If you are under age 59½, you will have to pay the 10 percent additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over. The 10 percent additional income tax does not apply to the following payments from the Plan Payments made after you separate from service if you will be at least age 55 in the year of the separation.

17 Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary). Payments from a governmentally defined benefit pension plan made after you separate from service if you are a public safety employee and you are at least age 50 in the year of the separation. Payments made due to disability. Payments after your death. Payments of ESOP dividends. Corrective distributions of contributions that exceed tax law limitations. Cost of life insurance paid by the Plan. Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment. Payments made directly to the government to satisfy a federal tax levy. Payments made under a qualified domestic relations order. Payments up to the amount of your deductible medical expenses. Certain payments made while you are on active duty if you were a member of a reserve component called to duty after Sept. 11, 2001, for more than 179 days. Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution. If I do a rollover to an IRA, will the 10 percent additional income tax apply to early distributions from the IRA? If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10 percent additional income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the 10 percent additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including There is no exception for payments after separation from service that are made after age 55. The exception for QDROs does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse). The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service. There are additional exceptions for Payments for qualified higher education expenses. Payments up to $10,000 used in a qualified first-time home purchase.

18 Payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status). Will I owe state income taxes? This notice does not describe any state or local income tax rules (including withholding rules). SPECIAL RULES AND OPTIONS If your payment includes after-tax contributions After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment. You may roll over a payment to an IRA that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a complete distribution of your benefit that totals $12,000, of which $2,000 is comprised of aftertax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions. You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over. If you miss the 60-day rollover deadline Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590, Individual Retirement Arrangements. If you were born on or before Jan. 1, 1936 If you were born on or before Jan. 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

19 If you are not the Plan participant Payments after death of the participant. If you receive a distribution after the participant s death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the 10 percent additional income tax on early distributions and the special rules for public safety officers do not apply, and the special rule described under the section If you were born on or before Jan. 1, 1936 applies only if the participant was born on or before Jan. 1, If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the IRA as your own or as an inherited IRA. An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59½ will be subject to the 10 percent additional income tax on early distributions (unless an exception applies), and required minimum distributions from your IRA do not have to start until after you are age 70½. If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10 percent additional income tax on early distributions. However, if the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions from the inherited IRA until the year the participant would have been age 70½. If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant s death, and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the inherited IRA will not be subject to the 10 percent additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA. Payments under a qualified domestic relations order. If you are the spouse or former spouse of the participant who receives a payment from the Plan under a QDRO, you generally have the same options the participant would have (for example, you may roll over the payment to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be subject to the 10 percent additional income tax on early distributions. If you are a nonresident alien If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20 percent, the Plan is generally required to withhold 30 percent of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (which may happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are

20 entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities. Other special rules If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series (unless you make a different choice for later payments). If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover. Unless you elect otherwise, a mandatory cash-out of more than $1,000 (not including payments from a designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan administrator or the payor. A mandatory cash-out is a payment from a plan to a participant made before age 62 (or normal retirement age, if later) and without consent, where the participant s benefit does not exceed $5,000 (not including any amounts held under that plan as a result of a prior rollover made to that plan). You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces Tax Guide. FOR MORE INFORMATION You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590, Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS office, on the Web at or by calling 800-TAX-FORM.

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University of Northern Iowa Direct Deposit of Payroll Authorization Form Name (Please Print) (Last, First, MI) UNI ID# I hereby authorize the University of Northern Iowa to initiate direct deposit credit

INSTRUCTIONS 1. Carefully read this application in its entirety before answering any questions. It is particularly important that you read and understand the Special Tax Notice Regarding Plan Payments.

Hardship Withdrawal Form READ THE ATTACHED IRS SPECIAL TAX NOTICE: IF YOUR PLAN ALLOWS FOR AN ANNUITY OPTION, READ THE WRITTEN EXPLANATION OF QUALIFIED JOINT AND 50% CONTINGENT SURVIVIOR ANNUITY FORM OF

Death Benefit Distribution Claim Form Non-Spousal Beneficiary READ THE ATTACHED IRS SPECIAL TAX NOTICE: IF THE PLAN ALLOWS FOR AN ANNUITY OPTION, READ THE WRITTEN EXPLANATION OF QUALIFIED JOINT AND 50%

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Annuitization Questions? Call our National Service Center at 1-800-888-2461. Instructions Please type or print. Use this form to begin annuity payments. Complete each section of the form. If you select

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Separation from Employment Withdrawal Request 401(k) Plan PERSI Choice 401(k) Plan 95270-01 When would I use this form? When I am requesting a withdrawal and I am no longer employed by the employer/company

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Death Benefit Claim Request Governmental 457(b) Plan Refer to the Death Benefit Claim Guide while completing this form. Use blue or black ink only. A certified death certificate must accompany this form.

Distribution Request Form READ THE ATTACHED IRS SPECIAL TAX NOTICE: IF YOUR PLAN ALLOWS FOR AN ANNUITY OPTION, READ THE WRITTEN EXPLANATION OF QUALIFIED JOINT AND 50% CONTINGENT SURVIVOR ANNUITY FORM OF

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Mailing Address: Des Moines, IA 50392-0001 Principal Life Insurance Company Early Withdrawal of Benefits Without Guaranteed Accounts No Spousal Consent Needed CTD00603 Complete this form to withdraw part

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Hardship Withdrawal Request 401(k) Plan Texa$aver 401(k) Plan 98960-01 When would I use this form? When I am requesting a withdrawal due to a Hardship. I should not use this form: If I have separated from